An ode to Drs Richard Cook, Jens Rasmussen & Bob Wears: A mini-compendium of their legacies

An ode to Drs Richard Cook, Jens Rasmussen & Bob Wears: A mini-compendium of their legacies

Ben Hutchinson Ben Hutchinson

Ben Hutchinson

HSE Leader / PhD Candidate

发布日期: 2025年2月17日
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This is long overdue - but I wanted to cover some of the work from these giants who have played a significant part in modern safety thinking.

Focus is on articles I've written about or used extracts from, or could find a full-text link for, and higher-cited articles. It's not systematic - and unfortunately a lot of the really cool stuff is locked behind paywalls.

I've also included some other authors who have leveraged the work from these researchers.

I think the target audience is more practitioners, since academics likely already have access to many of these.

Richard Cook


https://safety177496371.wordpress.com/2024/05/21/mistaking-error-an-earlier-paper-from-david-woods-richard-cook/


https://safety177496371.wordpress.com/2022/11/04/how-complex-systems-fail-a-classic-from-richard-cook/


https://safety177496371.wordpress.com/2025/01/26/those-found-responsible-have-been-sacked-some-observations-on-the-usefulness-of-error/


https://safety177496371.wordpress.com/2023/12/18/incidents-markers-of-resilience-or-brittleness/


https://safety177496371.wordpress.com/2022/11/03/nine-steps-to-move-forward-from-error/


https://pmc.ncbi.nlm.nih.gov/articles/PMC1117777/


https://www.researchgate.net/profile/Richard-Cook-8/publication/332248963_Operating_at_the_Sharp_End_The_Complexity_of_Human_Error/links/5ca94418299bf118c4b8b217/Operating-at-the-Sharp-End-The-Complexity-of-Human-Error.pdf


https://pmc.ncbi.nlm.nih.gov/articles/PMC1743994/pdf/v014p00130.pdf


https://www.researchgate.net/publication/245102691_A_Tale_of_Two_Stories_Contrasting_Views_of_Patient_Safety


https://www.academia.edu/download/83819345/Resilience_Engineering_New_directions_fo20220411-23835-1ipo8pk.pdf


https://www.academia.edu/download/39555606/Collaborative_cross-checking_to_enhance_20151030-28002-e6lstn.pdf


https://europepmc.org/article/NBK/nbk43670


https://www.academia.edu/download/81113052/download.pdf


https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=b4f626576f05e623fae22426ffef140d11999841


https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=97cac689ed97189fa977975bfba13e25c131ce48


https://www.researchgate.net/profile/David-Woods-19/publication/292504703_Distancing_Through_Differencing_An_Obstacle_to_Organizational_Learning_Following_Accidents/links/5742fb1808ae9ace8418b7ea/Distancing-Through-Differencing-An-Obstacle-to-Organizational-Learning-Following-Accidents.pdf


https://dl.acm.org/doi/pdf/10.1145/3380774.3380777


https://www.researchgate.net/profile/Richard-Cook-8/publication/228352596_Thinking_about_accidents_and_systems/links/5d30bac092851cf44090085e/Thinking-about-accidents-and-systems.pdf


https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=ffe74633027ee354ebbf0ff9a6418e75f3b7a047


https://journals.sagepub.com/doi/pdf/10.1177/2327857923121021


https://www.researchgate.net/profile/David-Woods-19/publication/267997924_The_New_Look_at_Error_Safety_and_Failure_A_Primer_for_Health_Care/links/5dee53664585159aa46fb254/The-New-Look-at-Error-Safety-and-Failure-A-Primer-for-Health-Care.pdf

https://www.researchgate.net/profile/Richard-Cook-8/publication/228352596_Thinking_about_accidents_and_systems/links/5d30bac092851cf44090085e/Thinking-about-accidents-and-systems.pdf


https://www.researchgate.net/profile/David-Woods-19/publication/14230576_Adapting_to_New_Technology_in_the_Operating_Room/links/0c96053beeb53e9cf9000000/Adapting-to-New-Technology-in-the-Operating-Room.pdf

https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=15f31969c4e1f4f599c5c68aa63f3bf930e0406f

https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=ffe74633027ee354ebbf0ff9a6418e75f3b7a047


https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=97cac689ed97189fa977975bfba13e25c131ce48

https://psychsafety.com/wp-content/uploads/2022/09/beingbump.pdf


https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=8e516e7eb67035a7a2021f3b67b488e762488323#page=99


JENS RASMUSSEN


https://backend.orbit.dtu.dk/ws/portalfiles/portal/158016663/SAFESCI.PDF


https://rib.msb.se/Filer/pdf/16252.pdf


https://www.iwolm.com/wp-content/downloads/SkillsRulesAndKnowledge-Rasmussen.pdf

https://backend.orbit.dtu.dk/ws/portalfiles/portal/158020073/ERTAX1.PDF


https://backend.orbit.dtu.dk/ws/portalfiles/portal/158019622/HISMC.PDF


https://backend.orbit.dtu.dk/ws/portalfiles/portal/137538698/ERRROLE_1_.PDF

https://backend.orbit.dtu.dk/ws/portalfiles/portal/158018718/ROYSOC.PDF


https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=5fb7644d205b342aa52c594b7982a9e208086238


https://backend.orbit.dtu.dk/ws/portalfiles/portal/105037994/TROUB.PDF


https://doi.org/10.1016/S0925-7535(00)00036-9


https://backend.orbit.dtu.dk/ws/portalfiles/portal/55672721/ris_m_2293.pdf


https://doi.org/10.1016/j.apergo.2016.10.002


https://backend.orbit.dtu.dk/ws/portalfiles/portal/158017532/DIAACT.PDF


https://backend.orbit.dtu.dk/ws/portalfiles/portal/53754046/ris_m_2519.pdf


https://backend.orbit.dtu.dk/ws/portalfiles/portal/158019420/AUTO.PDF


https://backend.orbit.dtu.dk/ws/portalfiles/portal/137294535/TREND.PDF


https://doi.org/10.1016/j.apergo.2015.10.015


https://backend.orbit.dtu.dk/ws/portalfiles/portal/158019864/LEPRAS.PDF


https://documents1.worldbank.org/curated/ru/535511468766200820/pdf/multi0page.pdf


https://backend.orbit.dtu.dk/ws/portalfiles/portal/53703058/ris_m_2349.pdf


https://backend.orbit.dtu.dk/ws/portalfiles/portal/104132737/ris_m_2139.pdf


https://repository.lboro.ac.uk/articles/conference_contribution/Methodological_considerations_in_using_AcciMaps_and_the_Risk_Management_Framework_to_analyse_large-scale_systemic_failures/9339965/files/16948643.pdf


https://uploadsproject.org/wp-content/uploads/2018/02/accepted-version-developing-a-contributing-factor-classification-scheme.pdf


https://www.academia.edu/download/66506126/SPE-174020-MS_Applying_the_AcciMap_Metho20210421-17955-gzen52.pdf


https://www.researchgate.net/profile/Brian-Thoroman/publication/340719717_Applying_AcciMap_to_test_the_common_cause_hypothesis_using_aviation_near_misses/links/5ea771f845851553fab5dcbd/Applying-AcciMap-to-test-the-common-cause-hypothesis-using-aviation-near-misses.pdf

https://backend.orbit.dtu.dk/ws/portalfiles/portal/55672022/ris_m_2240.pdf

https://backend.orbit.dtu.dk/ws/portalfiles/portal/158018718/ROYSOC.PDF


BOB WEARS


https://safety177496371.wordpress.com/2021/04/19/the-tragedy-of-adaptability/


https://safety177496371.wordpress.com/2024/10/29/the-science-of-human-factors-separating-fact-from-fiction/


https://safety177496371.wordpress.com/2024/03/20/relying-on-resilience-too-much-of-a-good-thing/


https://safety177496371.wordpress.com/2024/02/26/replacing-hindsight-with-insight-toward-better-understanding-of-diagnostic-failures/


https://safety177496371.wordpress.com/2023/09/22/a-bottom-up-approach-to-understanding-the-efficacy-of-event-analysis-in-healthcare-paradigm-shift-from-safety-to-resilience-engineering/


https://safety177496371.wordpress.com/2023/09/20/the-error-of-counting-errors/


https://safety177496371.wordpress.com/2023/01/20/resilience-skills-as-emergent-phenomena-a-study-of-emergency-departments-in-brazil-and-the-united-states/


https://safety177496371.wordpress.com/2021/03/18/our-current-approach-to-root-cause-analysis-is-it-contributing-to-our-failure-to-improve-patient-safety/


https://pmc.ncbi.nlm.nih.gov/articles/PMC1464040/

https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2015/10/safety-1-safety-2-whte-papr.pdf


https://www.academia.edu/download/85660593/468.full.pdf


https://www.researchgate.net/profile/Emily-Patterson-15/publication/41560739_Patient_Handoffs_Standardized_and_Reliable_Measurement_Tools_Remain_Elusive/links/5a044d15aca272b06ca93c3f/Patient-Handoffs-Standardized-and-Reliable-Measurement-Tools-Remain-Elusive.pdf


https://europepmc.org/article/NBK/nbk43670


https://www.annemergmed.com/article/S0196-0644(02)00030-6/abstract


https://www.annemergmed.com/article/S0196-0644(02)08255-0/fulltext


https://pmc.ncbi.nlm.nih.gov/articles/PMC4319563/

https://www.researchgate.net/profile/Robert-Wears/publication/225108705_Resilience_is_Not_Control_Healthcare_Crisis_Management_and_ICT/links/00b49532b2c7f3ed62000000/Resilience-is-Not-Control-Healthcare-Crisis-Management-and-ICT.pdf


https://www.researchgate.net/profile/Emily-Patterson-15/publication/257577242_YMEM3527/links/0deec52570545dac69000000/YMEM3527.pdf


https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/j.1553-2712.2000.tb00457.x

https://europepmc.org/article/nbk/nbk43774

https://onlinelibrary.wiley.com/doi/pdf/10.1197/j.aem.2004.07.001


https://www.annemergmed.com/article/S0196-0644(07)01451-5/fulltext

https://www.resilience-engineering-association.org/download/resources/symposium/symposium_2015/Wears_R.-Sutcliffe_K.-Safety-error-and-resilience-a-meta-narrative-review-Paper.pdf



Dinkar Gupta

Chief Information and Technology Officer (CIO/CTO) at KPMG Switzerland

4 天前

Thanks.. seminal papers and books that changed my thinking forever and I continue to learn from not just their work but all work inspired by their work.

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Susie Scott

Safety & Risk Executive | Human & Organizational Performance (Personal Account - Views expressed are my own)

1 周

This was so timely! Thank you Ben Hutchinson. You just filled the hole in my head that's been bugging me for a while. :)

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Glenn Wilson

#Cybersecurity professional #systems thinking practitioner #leadership coach / consultant #author

1 周

What an amazing collection to read through. Thanks for putting this together

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John Allspaw

Founder and Principal, Adaptive Capacity Labs

1 周

Oh very nice!

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